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Addressing
Alcohol Usepractice manualAn Alcohol Screening and Brief Intervention Program
FASD
FASDFAMILY &COMMUNITY
MEDICINE
Ensure
every patientwho uses alcohol is
identified,screened
for risky drinking, and
offered appropriate brief intervention,
referral, or treatment.Funding provided by U.S. Department of Health and Human Services, Centers for Disease Control and Prevention
Introduction ................................................................. 2
Promoting alcohol SBI .................................................3
Identify office champion(s)
Evaluate current system ...............................................4
Assess your practice environment and systems
Evaluate patient flow
Create a new patient flowchart
Identify barriers
Define a new system .....................................................6
Screen
Intervene
The five A’s
Teachable moments
Stages of change
Motivational interviewing
Develop strategies for change
Next steps
Follow-up
Relapse
Cultural considerations
Health literacy
Behavioral health
The five R’s
Standardize ..................................................................13
EHRs
Risky drinking registries
E-visits
Make assignments/team approach
Roles of multidisciplinary team members
Create feedback mechanism
Payment
Self-pay and uninsured patients
Medicaid
Private/commercial insurance carriers
Coding for alcohol SBI
Resistance to change .................................................18
Your implementation plan ..........................................19
Training ......................................................................... 20
Resources .................................................................... 20
References ....................................................................21
Contributing authors:
Sandra Gonzalez, MSSW, LCSW
John Grubb, MBA, JD
Alicia Kowalchuk, DO
Mohamad Sidani, MD, MS
Kiara Spooner, DrPH, MPH
Roger Zoorob, MD, MPH
Adapted from the Tobacco Cessation Toolkit as
developed by contributing authors:
Mary Theobald, MBA
Richard J. Botelho, BMedSci, BM, BS
Saria Carter Saccocio, MD, FAAFP
Thomas P. Houston, MD, FAAFP
Tim McAfee, MD, MPH
Sarah Mullins, MD
Thomas J. Weida, MD, FAAFP
TABLE OF CONTENTS
2 aafp.org/alcohol
Risky alcohol use, defined as any level of alcohol consumption which increases the risk of harm to oneself or others,
is both a substance use disorder and medical issue.1 Recognized as one of the leading preventable causes of death, risky
alcohol use leads to over 88,000 deaths each year in the United States.2 Among adults in the U.S., approximately 58% of
men and 46% of women report drinking in the last 30 days.3,4 National estimates also indicate that greater than 50% of the
alcohol consumed by adults is during binge drinking, the most common pattern of excessive or risky alcohol use.5 More
specifically, in the U.S., approximately 23% of adult men report binge drinking five times per month, while 11% of adult
women report binge drinking three times per month.6 Furthermore, research indicates that more than one in two women of
childbearing age drink alcohol. Among those that drink alcohol, 18% engage in binge drinking.7
Family physicians and other primary care providers are in an ideal position to facilitate the prevention of morbidity
and mortality associated with risky alcohol use.8 Many professional organizations recognize the importance of screening
and behavioral counseling interventions to reduce alcohol misuse, including the American Academy of Family Physicians
(AAFP), American College of Obstetricians and Gynecologists (AGOG), and the U.S. Preventive Services Task Force
(USPSTF).
Alcohol screening and brief intervention (SBI) is a USPSTF grade B recommendation that includes:
• Screening all adult primary care patients for risky alcohol use, at least yearly, using an evidence-based screening
tool.
• Providing a brief behavioral intervention to patients screening positive for risky alcohol use, to help them make
healthier choices around their drinking (e.g., to reduce alcohol use or quit drinking).
This practice manual provides a systems-change approach for implementing alcohol SBI into your practice.
“I now wish to emphasize to prospective parents, healthcare practitioners,
and all childbearing-aged women, especially those who are pregnant, the
importance of not drinking alcohol if a woman is pregnant or considering
becoming pregnant.”
- Richard Carmona, former U.S. Surgeon General
INTRODUCTION
aafp.org/alcohol 3
Primary care practices are transforming from
condition- and treatment-centered practices to patient-
centered medical homes (PCMHs) and other enhanced
quality improvement models. The PCMH model of care
delivery for primary care practices holds the promise of
higher quality care, improved self-management by patients,
and reduced costs. This model offers your practice a
prime opportunity to improve alcohol SBI. It is based on a
continuous relationship between the patient, the physician,
and the health care team, and requires the team to take
collective responsibility for the patient’s ongoing care.
More information about the PCMH model is available at
www.aafp.org/pcmh.
There are numerous ways to develop and establish
alcohol SBI in your family medicine practice. The most
important aspect is to get the entire staff, as well as your
patients, thinking and talking about reducing risky drinking.
Examples of how to demonstrate an alcohol SBI culture in
your practice include the following:
• Making sure magazines in your exam rooms and
waiting areas do not have alcohol ads.
• Encouraging staff to assess their own drinking
patterns and make healthier choices or seek
additional help if needed.
• Placing visual cues, such as posters and
brochures, throughout the office to encourage
“knowing your limits” and “discussing alcohol use
with your physician” (see page 20 for information
on available resources).
• Educating all staff on an ongoing basis, by offering
training (e.g., lectures, workshops, in-service) on
alcohol SBI and providing continuing education
(CE) credits and other incentives for participation.
Identify office champion(s)Select one or more persons in your practice to act as
an alcohol SBI office champion(s). Office champion(s)
play a critical role in providing overall leadership for
alcohol SBI efforts. The champion(s) should be charged
with recommending and implementing system changes
to integrate alcohol SBI into your practice’s daily office
routines.
Choose champions who are passionate about helping
staff and patients avoid risky drinking so they can live
healthier lives. Give your champion(s) the time, power, and
resources to institute real change. Foster a collaborative
process, allowing all staff and clinicians to provide input
into realigning processes. Your practice may want to form
a committee to assist the champion(s) in planning and
implementing change and measuring success.
PROMOTING ALCOHOL SBI
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4 aafp.org/alcohol
1. How does your practice currently identify and document
alcohol use by patients?
Whose responsibility is this?
2. How does your practice environment currently
communicate to patients the health effects of
at-risk drinking and your ability to assist them?
(Select all that apply)
o Posters in waiting areas
o Posters in exam rooms
o Self-help materials in waiting areas
o Self-help materials in exam rooms
o Lapel pins
o Other
3. How does your practice currently help patients who are
drinking alcohol at risky levels?
(Select all that apply.)
o Distribute educational materials
o Refer patients to self-help groups such as
Alcoholics Anonymous
o Refer patients to outside support groups,
counseling or alcohol use disorder treatment
options
o Conduct alcohol brief therapy group visits
o Counsel patients at visits
o Provide follow up for patients making a reduce
alcohol use or quit attempt
This section will help you think about how your practice currently functions so you can identify small changes you can
make to integrate alcohol SBI activities.
Assess your practice environment and systems
4. What systems do you have in place to make sure alcohol
use is addressed at patient visits?
o Prompts in electronic health record (EHR)
system
o Risky alcohol use status as part of vital signs
o Registry of patients who use alcohol at risky
levels
o Flags or stickers on paper charts
o Feedback to clinicians on adherence to
guidelines
o Regular staff training
o Other
5. Imagine that your practice is successfully doing everything
possible to help patients with risky alcohol use to reduce
alcohol use or quit. How would that look?
6. What are some of the challenges you face in identifying
patients who drink at risky levels to help them reduce
alcohol use or quit?
7. What has worked in terms of helping patients reduce
alcohol use or quit drinking? What has not worked?
8. Whose responsibility is it to advise patients to reduce
alcohol use or quit and to provide counseling and
resources?
9. What resources are available in your community that your
patients could access for help with their quit attempts?
EVALUATE CURRENT SYSTEM
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Evaluate patient flowTake a moment to examine how patients flow through your office. This will help you identify opportunities to expose
patients to alcohol SBI messages and offer adequate support from staff. Create a simple document that shows how
patients advance through your system, from the time they enter until the time they leave.
Think about the following questions, relative to alcohol SBI, as you document your current patient flow.
1. Where do patients go when they enter the office? What do they see and do before they are called back for their visit?
2. Who do patients see before meeting the clinician?
3. What questions are asked when vital signs are measured?
4. What information is exchanged with patients before the patient-clinician encounter?
5. How do clinicians support alcohol SBI during the encounter?
6. How is alcohol SBI counseling documented?
7. What reminder systems and prompts are in place to alert clinicians of opportunities to discuss risky drinking?
8. What path do patients take as they exit the office? Do they make any stops to speak with staff?
Create a new patient flowchartBased on your observations, create a new flowchart that shows how and where you will communicate with patients
about risky drinking.
Patient sits in waiting roomPosters, brochures, referral cards
Height and weight checked in hallwayPosters, brochures, referral cards
Patient meets with counselor
Patient stops at billing/scheduling station
Patient leaves
Patient meets with clinician
Remaining vital signs checked in exam room
Patient checks in
Sample patient flowchart Clinician:
• Advise patient to reduce alcohol use or quit.
• Assess willingness to reduce alcohol use
or quit.
• Counsel and/or refer (internally or
externally) for development of change plan.
Nurse or Medical Assistant:
• Develop change plan and set start date.
EVALUATE CURRENT SYSTEM
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Identify barriersWhat challenges do you expect to experience as you make system changes to identify and counsel patients who use
alcohol at risky levels? This manual provides solutions to those challenges.
A team meeting to identify potential barriers is a great place to begin your system redesign. For many clinicians,
common barriers to alcohol SBI include: the need for an alcohol SBI model/system; lack of time; perceived lack of
payment for intervention; and lack of engaged staff who may themselves drink at risky levels and don’t perceive any
problems with their drinking. Staff members who are risky drinkers may be uncomfortable assisting patients with changing
their drinking patterns.
Now that you have evaluated your current system, it is time to take steps to define and implement a system to ensure
that alcohol use is systematically assessed and intervened upon at least yearly.
The alcohol SBI program, “Screen and Intervene” encourages family physicians to SCREEN their patients for risky
drinking, and then INTERVENE to help them make healthier choices around their alcohol use. This easy-to-remember
approach provides the opportunity for every member of a practice team to intervene at least yearly. Interventions can be
tailored to a specific patient based on his or her willingness to reduce alcohol use or quit, as well as to the structure of the
practice and each team member’s knowledge and skill level.
Many family medicine practices lack systems to do
the following:
• Track patients to determine who needs preventive
services and remind them to get the services
• Prompt clinicians to deliver preventive services
when they see patients
• Ensure services are delivered correctly and that
appropriate referral and follow up occur
• Confirm that patients understand what they need
to do9
Another potential barrier is having
inappropriate expectations about alcohol SBI.
Alcohol SBI works best with patients who drink
at risky levels, but who do not have an alcohol
use disorder. These patients have been shown
to respond to brief behavioral interventions
focused on helping them reduce their drinking
to less risky levels. For patients identified
through alcohol SBI as having an alcohol use
disorder, it should be considered a chronic
condition, and needs to be treated with the
expectation that most patients will be helped,
but may experience relapses and remissions,
rather than immediately quitting on the
first try.10
DEFINE A NEW SYSTEM
EVALUATE CURRENT SYSTEM
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ScreenThe first step in your process redesign should be to
make sure that risky alcohol use status is queried and
documented for every patient at least yearly.
If you are using paper records, expand the vital signs
to include risky alcohol use. Electronic health records
(EHRs) allow for integration of the alcohol SBI protocol into
the practice workflow, facilitating system-level changes to
reduce risky drinking. Prompts on face sheets or summary
screens can help you easily identify patients who drink at
risky levels, similar to a chart sticker or flag. These prompts
can be specific to risky drinking, with status embedded in
the social history, or they can be generic chart reminders
that your practice customizes. For example, many EHRs
have pop-up reminders that could contain a query about
risky alcohol use. After the initial identification of the patient
as a risky drinker, the EHR should then be programmed to
remind the clinician to ask the patient about their drinking
at subsequent visits.
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
Ask, identify and document the risky alcohol use status of every patient at least yearly.
In a clear, strong, and personalized manner, advise every risky drinker to reduce alcohol use or quit.
For the current risky drinker, assess whether the patient is willing to reduce alcohol use or quit at this time.
For the patient willing to reduce alcohol use or quit, arrange for follow-up contacts, beginning within the first week
after the change date.
For the patient unwilling to reduce alcohol use or quit at this time, address risky drinking and willingness to reduce
alcohol use or quit at their next clinic visit.
For the patient willing to reduce alcohol use or quit, assist them to develop a personalized plan for how and when to do so, provide or refer for counseling or additional behavioral treatment, and prescribe medication to help the patient who has an alcohol use disorder get and maintain sobriety.For patients unwilling to change their drinking at this time, provide interventions designed to increase readiness to change. For the patient who recently reduced alcohol use or quit and for the patient facing challenges to remaining alcohol free, provide relapse prevention, including medication as needed.
InterveneOnce you have screened and found that a patient is
drinking at risky levels, it is important to take appropriate
action, advising the patient to reduce alcohol use or quit
and assisting those who are willing to make a change.
Alcohol brief interventions are just that — brief, not
lengthy. Even brief counseling sessions help patients
successfully make changes in their drinking. Substance
use disorder counseling combined with medication is
the most effective treatment for patients with alcohol use
disorders (AUDs), so referral to community treatment
programs may be needed.
The five A’sAccompanying the ‘Screen and Intervene’ approach
is a framework used to promote reducing or quitting
addictive behaviors, such as tobacco use. The five A’s
framework (ask, advise, assess, assist, and arrange) is
adapted for alcohol use in the table below. Along with
‘Screen and Intervene,’ physicians can use these steps
to help promote the reduction of alcohol use or quitting
for patients.
DEFINE A NEW SYSTEM
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Teachable momentsOne way to effectively help patients become interested
in reducing alcohol use or quitting is to recognize, create,
and capitalize on “teachable moments.” A teachable
moment is a point in a patient visit when you are able to
reshape the conversation from advice giving into shared
decision making. This opportunity often arises when
patients are presented with information that requires them
to pay attention to or process new information. Capitalize
on teachable moments to discuss healthy lifestyle choices.
Some key “teachable moment” opportunities include:
• New patient visits
• Annual physicals
• Women’s wellness exams or family planning visits
• Prenatal visits
• Problem-oriented office visits for the many diseases
caused or affected by risky alcohol use (e.g.,
gastroesophageal reflux disease, peptic ulcer
disease, diabetes, hypertension, liver disease)
• Follow-up visits after hospitalization for an alcohol-
related illness
• A recent health scare
A major component of any conversation should be
assessment of patients’ attitudes toward and readiness to
change. As you capitalize on teachable moments, actively
engage patients in conversations to do the following:
• Start a dialogue.
• Motivate a desire for behavior change and
eliminate resistance to change.
• Help patients set goals that are specific,
measureable, attainable, realistic, and time-based
(SMART).
• Improve continuity of care.
DEFINE A NEW SYSTEM
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Stages of changeThrough patient-centered conversations, you will identify your patients’ current readiness to change and help them
advance through the stages of change,11,12 with the ultimate goal of getting them to take action to reduce alcohol use or
quit drinking.
STAGE DEFINITION GOALS OF STRATEGIES CONVERSATION
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Not interested in changing
Considering pros and cons of changing, but not committed to taking action
Making plans to change within the next month
Taking action to change behavior
Change becomes a way of life
Have changed for six months or more
Resumption of old behaviors
Increase awareness of need to change without criticizing
Motivate and increase confidence
Motivate patient to take action
Support desire for change
Confirm that changing is possible
Reaffirm commitment and arm with strategies for success
Reduce risk of relapse
Plan for potential difficulties
Use support network
Overcome shame and guilt
Use relapse as a learning experience
Personalize risks, but avoid scare tactics
Offer to help when they’re ready to change
Discuss benefits of change and risks of not changing
Explore concerns and fears (i.e., barriers)
Help individualize a plan for changing
Set realistic goals
Provide and have patient seek social support
Set change date
Schedule follow up
Refer to self-help meetings (e.g., Alcoholics Anonymous)
Refer to community treatment programs
Provide educational materials
Discuss over the counter vitamins (e.g., folic acid and thiamine)
Identify triggers
Teach behavioral skills
Reinforce benefits
Celebrate success
Follow up
Refer to community treatment programs
Identify ongoing triggers
Reaffirm behavioral skills
Resolve problems
Reassure that relapse is a normal learning experience
Facilitate another change attempt
Identify successful strategies and barriers
DEFINE A NEW SYSTEM
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Motivational interviewingMotivational interviewing is goal-directed counseling to
motivate behavior change. Motivational interviewing uses
the OARS technique to help patients move through the
stages of change. OARS is an acronym for:
• Open-ended questions
• Affirmation
• Reflective listening
• Summaries
When using the OARS technique to talk to patients
about their alcohol use, do the following:
• Express empathy — When patients think you are
listening to them and understand their concerns,
they will be less defensive and may be more likely
to open up. As they talk, you can assess areas in
which they need support.
• Support self-efficacy — Make your patients
responsible for identifying the changes they want
to make. Focus your attention on helping them
believe that they can change.
• Point out previous successes they have had or
how other patients have successfully reduced
alcohol use or quit.
• Roll with resistance — Don’t challenge patients
who resist change. Instead, ask them what their
solution is for the problem they have identified.
• Develop discrepancy — Help patients see the
discrepancy between where they are and where
they want to be.12
More information about motivational interviewing is
available at www.motivationalinterviewing.org.
Develop strategies for changePatients who are motivated to reduce alcohol use or
quit will need help developing strategies for behavioral
change. Patients are typically more successful in their
change attempts if they receive counseling over multiple
visits. Support can be provided by multiple clinicians.
Practical counseling, which teaches problem-solving skills,
is especially effective.
When a patient leaves your office after setting a
specific reduction in alcohol use target or quit date,
support the attempt with doctor’s orders for the change.
This serves as a form of contract and also provides
practical tips on what to do before, on, and after the
change date.
Next stepsProviding support and follow up to patients motivated
to quit is a challenging part of implementing a systematic
approach to helping risky drinkers reduce alcohol use or
quit. Practices can provide follow-up support to ensure
each patient’s efforts to reduce alcohol use or quit by
reassessing at subsequent clinical visits for other health
concerns. A good way to do this is by having a flag or
notation in the EHR to remind the clinician to follow up.
For patients with an AUD being referred to community
treatment resources, a follow-up visit specifically scheduled
to address their progress with engaging those resources
and to provide primary care support in early recovery is
helpful. Some practices will find having a nurse or health
educator make follow-up contact with patients checking
in on their progress with making and sustaining change at
regularly set intervals such as weekly or monthly to be an
effective strategy.
DEFINE A NEW SYSTEM
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Follow upAfter a patient has made a commitment to reduce
alcohol use or stop drinking, it is important to monitor
progress. Patients often have stressors that can derail their
change attempts.
When formulating a follow-up plan, consider the
appropriate intervals and the contact method that will work
for both clinician and patient.
• When? — Plan to follow up with patient on their
change date a week later, and about a month later.
• Who? — Frequency of contact is a major
determinant of success, but the contact need
not be limited to direct, in-person visits with a
physician. For example, dieticians, nurses, and
health educators can maintain frequent contact
with patients.
• How? — In addition to in-office follow-up visits, you
can arrange for e-visits, telephone visits, or email
communication. Follow-up calls and/or visits
should include discussions about the following:
• The benefits of reducing alcohol use or quitting
• How social support is working
• Behavioral effects of the change and ways to deal
with these
• Positive achievements, such as creating an
alcohol-free outcome and using a designated
driver
• How you and your team can help
Most people change behavior gradually. Patients
cycle forward and backward through the following stages:
uninterested, unaware, or unwilling to make a change
(precontemplation); considering a change (contemplation);
deciding and preparing to make a change (preparation);
modifying behavior (action); and avoiding a relapse
(maintenance).11
Relapses of some sort are almost inevitable. An
adequate, individualized plan for support and follow up will
help your patient with his or her change efforts.
RelapseA relapse is generally considered to be a return to
drinking that leads to a return to previous levels of alcohol
consumption.
Relapse is part of the process of lifelong change. Do
not view relapse as failure. Patients may think this way,
so you might want to explain that some relapse is to be
expected. Most patients try several times before they
successfully sustain change.
Patients who relapse should leave your office with
a sense that they can successfully reduce alcohol
use or quit.
Similarly, try to avoid thinking of patients who relapse
as non-compliant or unmotivated. These labels do not
account for the complex nature of behavioral change or
the physiologic effects of risky drinking. Remember, you
are helping your patient overcome a chronic condition.
When counseling a patient who has relapsed, begin
by normalizing the situation and focusing on the positive.
Explain to the patient that even though a relapse has
occurred, he or she has learned something new about the
process of changing behavior.
Ask what got in the way. Have the patient identify
obstacles. Note that this is not a “why” question. If you
assume that relapse is normal and expected, the “why” is
already answered.
Acknowledge the difficulty of the behavioral
change and provide encouragement. Support
patients and help them re-engage in the
change process.
Help the patient focus on the details of the obstacles,
which will help facilitate problem solving. Some situations
are not changeable, so the patient will have to discover
strategies to overcome these challenges.
Ask how the patient will deal with the same situation
in the future. This conversation will help the patient shift
the focus from failure to problem solving. Patients will be
more vested in solutions if they come up with them. As part
of this discussion, you can have the patient identify what
worked previously.
DEFINE A NEW SYSTEM
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Acknowledge the difficulty of the behavior change and
provide encouragement. Support patients and help them
re-engage in the change process.
Have the patient make a new plan or modify the
current one. Shorten the interval between repeat visits.
Consider using phone calls or e-visits for patients who are
having difficulty reaching their goals.
Cultural considerationsIt is likely that you see patients from a variety of
cultural and ethnic backgrounds. As you encourage
these patients to reduce alcohol use or quit, be aware
of traditions or ingrained social or cultural customs (for
example, ceremonial alcohol use) that might pose barriers
to successful change. Help patients see how the benefits
of reducing alcohol use or quitting outweigh any social
benefits of drinking. Having patient-centered conversations
will help ensure that goals and action plans are culturally
and linguistically appropriate.
Health literacyHealth literacy can be defined as “the degree to which
individuals have the capacity to obtain, process, and
understand basic health information and services needed
to make appropriate health decisions.” 13 Nearly nine out
of 10 adults may not possess the skills they need to assist
them in managing their health and preventing disease.14
Patients with low health literacy may not comprehend
drug labeling or medical instructions, with the result that
they appear unwilling to follow recommendations. Patients
may not understand health publications, may not give an
adequate history, may be unable to provide truly informed
consent, and may have difficulty completing medical and
insurance forms.
You may want to assume that some of your patients
have limited health literacy. Consider the following
recommendations:
• Create an environment in which patients feel
comfortable talking to you.
• Use plain language instead of medical jargon or
technical language.
• Sit down to achieve eye-level communication.
• Use visual models to illustrate a procedure or
condition.
• Have patients explain back to you the care
instructions you gave them or demonstrate
procedures you explained.
Behavioral healthRates of risky drinking and alcohol use disorders are
higher among people who have mental health disorders
and other substance use disorders than in the general
population.15
All people who drink at or above risky levels and
have a mental health disorder, including those who have
another substance use disorder, should be offered brief
intervention and referral to treatment as needed. Treating
alcohol use disorders in individuals who have a mental
health disorder is made more complex by the potential for
multiple diagnoses and multiple medications.10
Patients who have a mental health disorder can
successfully reduce alcohol use or quit drinking.
Counseling is critical to their success. These patients will
likely need more and longer counseling sessions, and they
may need more time to prepare for their change attempt.
Using motivational interviewing and the Five Rs listed
below can also be effective. This system is targeted at
patients who are drinking at risky levels, and are not yet
ready to quit. It can motivate change by helping them
understand the importance of reducing alcohol use or
quitting in personal terms.
DEFINE A NEW SYSTEM
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The five RsRelevance. Why is reducing alcohol use or quitting
relevant to this patient? For example, maybe he or she has
had a personal health scare, such as a recent heart attack,
or upper gastrointestinal bleed.
Risk. Ask the patient to list negative effects of their
alcohol use. These may include short-term risks, long-term
risks, and damage to their health and relationships.
Rewards. Ask the patient to list benefits of reducing
alcohol use or quitting. These may include being healthier,
saving money, setting a good example, or having better
self-esteem.
Roadblocks. Ask the patient to identify barriers to
reducing alcohol use or quitting. Then talk about ways to
address these barriers. For example, if a patient is worried
about withdrawal symptoms or cravings, ease his or her
fears by describing medication options that can help and
refer to community treatment providers who can manage
those symptoms.
Repetition. The health care team should repeatedly
follow up with the patient, keeping in mind that it may take
repeated attempts to reduce alcohol use or quit, especially
for patients with a behavioral health disorder.10
To reduce alcohol use or quit, patients may need to
rely on more than one method at a time. In addition to
counseling, methods may include step-by-step manuals,
phone support, self-help meetings, and/or prescription
medications. It is important for those who drink alcohol
and live with a mental health disorder to work with a
health care professional to determine the most effective
strategies.
Patients who have co-occurring behavioral health
disorders may need medication to manage withdrawal
symptoms, which can be more severe than those in the
general population. It is very important to customize
pharmacotherapy for these patients in a specialty care
setting. Take into account a patient’s current medications,
previous quit attempts, access to affordable medication,
and personal preferences.
DEFINE A NEW SYSTEM
In particular, physicians need to carefully monitor the
dosage and effects of psychiatric medications during
reduce alcohol use and quit attempts by patients who
have a behavioral health disorder. Because ongoing
use of alcohol may modulate psychiatric symptoms and
medication side effects, changes in a patient’s drinking
status require close follow up.
Now that you have a broad understanding of effective
alcohol SBI, it’s time to standardize your office systems to
ensure that every patient who uses alcohol at risky levels
is identified, advised to reduce alcohol use or quit, and
offered referral to evidence-based community treatment
programs when necessary.
Electronic health records (EHRs)EHRs allow for integration of the alcohol SBI into the
practice workflow, facilitating system-level changes to
reduce risky drinking.
Beyond identifying risky drinking status, the EHR
should include automatic prompts that remind clinicians
to provide risky drinkers a brief intervention, and connect
patients and families to appropriate community treatment
program resources when needed.
STANDARDIZE
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Risky drinking registriesA risky drinking registry is a list of all your patients who
drink alcohol at risky levels. The entire care team can use
this list to keep track of which patients need services and
to get a population-based view of how well your practice is
meeting care guidelines. Registries make it easier for your
practice to reach out to patients who do not seek the care
they need.
Ideally, you will want your registry to encompass your
entire patient population, but you can start small and add
data over time.
There are dozens of ways to create a registry. You can
create a simple spreadsheet or use a standard database
program. There are several registry applications you can
download or use online for free. There are also robust
applications you can buy. Newer EHR systems often have
registry functionality built into the system.
While creation of a registry does not require the hiring
of additional staff, you and your practice team will need to
create a process for using the registry to prepare for and
conduct patient visits, as well as to follow up with patients.
It is important to clearly define who is responsible for each
step in the process.
Registries give you the opportunity to monitor the
performance of each member of the health care team and
the team as a whole. Peer comparisons can be a great
incentive for improved care.
A registry creates an opportunity to capture, organize,
and analyze information about your patients who
drink alcohol at risky levels.
E-visitsElectronic medical appointments, or e-visits, take
place online through a secure email system or patient
portal. E-visits are generally initiated by a patient, who
enters information about his or her medical condition.
After the patient sends a request, it is triaged to a
physician or a nurse practitioner who communicates
treatment recommendations. The patient then receives
an email notification to log back into the system to view
the recommendations. E-visits are an efficient way to
provide follow-up care to patients during their alcohol use
reduction or quit attempts.
Make assignments/team approach
As you implement your practice’s process of change,
bring together your health care team. Led by your office
champion(s), discuss how best to adapt alcohol SBI into
your practice setting. The team must do the following:
• Select resources to be used in the office and
determine how they will be stored, distributed, and
accessed.
• Choose who will discuss alcohol-related issues
with the patient, how and when this will happen,
and where the responses should be documented
on the chart. Remember that the patient’s success
increases in proportion to the number of staff
involved in the process.
• Decide who will help the patient develop an
alcohol use reduction or quit plan. Physicians have
a slightly higher success rate engaging patients
in brief encounters, but interventions by non-
physician clinicians are nearly as successful.
• Discuss how the team will provide any needed
referrals and follow-up care for patients in the
alcohol use reduction or quit process and create
mechanisms to ensure that this care is provided.
STANDARDIZE
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Roles of multidisciplinary team membersSystematizing processes requires very clear guidelines on roles and responsibilities. Assignments may vary based on
practice size and structure. As you define who will assume various roles in your practice’s alcohol SBI process, consider
the following options:
Physicians
• Deliver strong
personalized advice to
reduce or stop drinking
• Assess readiness to
reduce or quit drinking
• Deliver brief
interventions to patients
who are ready to reduce
or quit drinking
• Refer patients with
AUDs to community
treatment providers
• Refer patients to
other team members
for supplemental
counseling
• Perform follow-up
counseling during
alcohol use reduction
and quit attempts
• Keep current on
research and medical
knowlege
Nurses, physician assistants, and/or health educators
• Assess risky drinking
status of patients and
their readiness to
reduce alcohol use
or quit
• Provide counseling, with
a focus on identifying
strategies to avoid
triggers, cope with
cravings, and get
social support
• Perform follow-up
counseling during
alcohol use reduction
and quit attempts
Receptionists/medical assistants
• Distribute health
questionnaire and
specific alcohol
screening tools to
identify risky drinking
status of patients and/
or collect information
about drinking history
and readiness to reduce
alcohol use or quit
• Ensure general
information and self-
help materials are in
waiting areas and exam
rooms
• Schedule follow-up
appointments for
alcohol cessation visits
• Make follow-up calls to
patients during alcohol
use reduction or quit
attempts
• Assist patients in
connecting with
community treatment
providers when referred
by their clinician
Administrators
• Ensure adequate
human resource
support for staff
engaging patients
with alcohol SBI (e.g.,
the office champion’s
duties)
• Support integration of
alcohol SBI tools into
the EHR
• Arrange for alcohol SBI
training opportunities
for staff
• Implement quality audits
and monitor quality of
key implementation
activities
• Ensure data are tracked
for program evaluation
• Communicate
outcomes to other
members of the health
care team
STANDARDIZE
Be sure to communicate to each staff member about his or her responsibilities in the delivery of
alcohol SBI. Incorporate a discussion of these staff responsibilities into training of new staff.
16 aafp.org/alcohol
Create feedback mechanismAs with any quality improvement process, data
are necessary and feedback is essential to system
improvement. Several elements can be measured and
reported, such as the following:
• The number and/or percentage of risky drinkers in
the patient population
• The number and/or percentage of patients
advised to reduce alcohol use
• The number and/or percentage of patients who
reduce alcohol use
• Success rates at 1, 6, and 12 months, etc.
Provide feedback to clinicians and staff about their
performance, drawing on data from chart audits, electronic
medical records, and computerized patient databases.
Evaluate the degree to which your practice is identifying,
documenting, intervening with, and referring patients who
are drinking at risky levels.
Physicians will be interested in data on the outcomes
of patients with AUDs referred to community treatment
providers. It may also be helpful to note the number of
patients who reduce alcohol use or quit spontaneously
without much assistance.
Set benchmarks or target goals. Use a few minutes
in regular staff meetings to share information about the
alcohol SBI process. Include unblinded data in internal
practice communications. Reinforcing the importance
of alcohol SBI efforts and continuously creating ways to
improve the system are crucial to success.
Formal, regular communication about how the
alcohol SBI process is working should be
integrated into the system.
PaymentAs you adjust your systems, be sure to involve those
who do your medical billing. Patient visit forms and
electronic claims systems may need to be modified to
include alcohol SBI codes. Clinicians will also need to
be educated on appropriately documenting treatment to
ensure payment for services.
Self-pay and uninsured patientsThe following resources are for patients who do not
have insurance, or who have limited insurance coverage:
• Self-help groups (e.g. Alcoholics Anonymous)
• Flexible spending accounts, if alcohol cessation is
an allowable expense
• Employee assistance programs (EAPs), in some
cases
• Community resources and support groups
• Out-of-pocket spending
• Online resources
MedicaidMany states offer some payment for alcohol screening
as a preventive service for Medicaid patients. Such
screening typically must be performed by a physician or
other licensed practitioner. Brief intervention counseling
may also be covered, and each state establishes its own
provider qualifications for payment of such services. You
are encouraged to contact your state Medicaid office for
coverage information in your state.
Private/commercial insurance carriers
Private insurers are required under most plans to
provide evidence-based alcohol screening and counseling
to all adults, pregnant women, and children beginning at
age 11 as a preventive service. This is provided without
a copayment or coinsurance to the patient. However,
there may still be a facility fee or other chargeable service
involved in providing the screening, so you should check
with individual insurance plans to determine what specific
interventions are included and the extent to which these
interventions are covered.
STANDARDIZE
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Use the following codes for patients receiving a screening only.
STANDARDIZE
Coding for alcohol SBIIn 2014, the Patient Protection and Affordable Care Act (ACA) began requiring insurance plans to cover many clinical
preventive services. Two of the covered preventive services include:
• Alcohol screening for adults
• Alcohol screening and brief intervention
CPT CODE PAYER DESCRIPTION
96160 Commercial Administration and interpretation of health risk assessment instrument Insurance
G0442 Medicare Screening for alcohol misuse in adults including pregnant women once a year; 15 min.
Use the following codes for patients with a positive screen result and receiving brief intervention counseling.
CPT CODE PAYER DESCRIPTION 99408 Commercial Alcohol and/or substance abuse structured screening and brief intervention Insurance, services; 15 to 30 min. Medicaid
99409 Commercial Alcohol and/or substance abuse structured screening and brief intervention Insurance, services; greater than 30 min. Medicaid
G0396 Medicare Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 min.
G0397 Medicare Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 min.
G0443 Medicare Up to four, 15 min. brief face-to-face behavioral counseling interventions per year for
individuals, including pregnant women, who screen positive for alcohol misuse
H0049 Medicaid Alcohol and/or drug screening (not widely used)
H0050 Medicaid Alcohol and/or drug service, brief intervention, per 15 min. (not widely used)
ICD-10 CM DESCRIPTION
Z13.89 Encounter for screening for other disorder
Z13.9 Encounter for screening, unspecified
Z71.41 F10.10 Alcohol abuse counseling and surveillance of alcohol
Z71.42 Counseling for family member of a person with an AUD
18 aafp.org/alcohol
In any organization or group, including a medical
office, change can be threatening, even if new ideas
or processes lead to improvement. No matter how well
changes are communicated prior to their implementation,
some people will resist.
It is very important for the alcohol SBI office
champion(s) to anticipate resistance and plan strategies
for dealing with it. This applies not only when the
change is introduced, but also over the long term. Clear
communication is imperative. For example, the office
champion(s) should spell out how changes will affect the
office, how patient care will be improved, and how roles
and responsibilities are defined.
Office leadership needs to present changes
in a united, positive way, creating opportunities for
communication, staff input, feedback and improvement in
the new system, and shared goals for both operations and
improved patient care outcomes.
Your office clinicians and staff will be more willing to
accept change if they:
• Like the way the change is communicated and feel
included in the process
• Like and respect the source of the change
• Understand the motivation and goals for the
change
• Feel a sense of challenge and satisfaction
• Are allowed to help put the new plan into place, as
opposed to having it forced on them
RESISTANCE TO CHANGE
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Put your new ideas into action. Use this worksheet to develop a plan for systems change. This is intended to provide a
basic checklist and should not limit the development of a system for your office.
TASK
Conduct initial meeting with staff
Create alcohol SBI supportive atmosphere
Hang posters in waiting area
Hang posters in exam rooms
Display self-help materials in waiting areas/exam
rooms
Check magazines for alcohol ads
Other
Flow chart the patient experience and highlight
opportunities for alcohol interventions
Update vital signs (if needed)
Create EHR or paper flags, prompts, and templates
Formalize alcohol SBI protocol (Identification of risky
drinkers, counseling, medication, referral, follow up)
Provide staff training
Update billing process to ensure payment
Create list of community resources, including
evidence-based treatment programs
Create patient registry
Plan for group visit
Create and implement system to track and
communicate success
Make staff assignments. What is the role of:
Physicians(s)
Nurse(s)
Health educator(s)
Medical assistant(s)
Administrator(s)
Receptionist(s)
YOUR IMPLEMENTATION PLAN
PERSON DATE TO BE CHECK WHENRESPONSIBLE COMPLETED COMPLETE
20 aafp.org/alcohol
This manual provides a broad overview of alcohol screening and brief intervention. If you or members of your practice
team are looking for additional training, check out the following resources:
The Arc of the United States: In addition to the toolkit referenced below, the Arc offers webinars on reducing risky
drinking and prevention of fetal alcohol spectrum disorders (FASDs):
http://www.thearc.org/FASD-Prevention-Project/training/webinar-archive
University of Missouri Alcohol and Drug Education for Prevention and Treatment: Online continuing medical
education (CME) training entitled “Addressing Alcohol and Drug Problems with your Patients: Doing it Skillfully, Effectively,
and Comfortably” is available at:
https://adept.missouri.edu/Training/TrainingOverview.aspx
The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a variety of resources on FASD,
including a course for addiction professionals, on their website at:
https://www.samhsa.gov/fetal-alcohol-spectrum-disorders-fasd-center
The Arc FASD Prevention Project Toolkit: A conversation guide, resource guide, FASD reminder stickers, and posters
to enable consistent messaging about the risks of drinking while pregnant:
http://www.thearc.org/FASD-Prevention-Project/resources/toolkit
Centers for Disease Control and Prevention (CDC):
https://www.cdc.gov/alcohol
CDC’s Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for
Primary Care Practices:
https://www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf
The Institute for Research, Education & Training in Addictions’ (IRETA) Screening, Brief Intervention, and Referral to
Treatment (SBIRT) Reimbursement Map: Information on billing and coding for SBI services.
http://my.ireta.org/sbirt-reimbursement-map
Baylor College of Medicine – FASD Practice & Implementation Center:
https://www.bcm.edu/fasd-pic
TRAINING
RESOURCES
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1. Centers for Disease Control and Prevention. Planning and implementing screening and brief intervention for risky alcohol use: a
step-by-step guide for primary care practices. Atlanta, Georgia: National Center on Birth Defects and Developmental Disabilities;
2014. https://www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf. Accessed June 2, 2017.
2. Centers for Disease Control and Prevention. Alcohol-related disease impact (ARDI).
https://nccd.cdc.gov/DPH_ARDI/default/default.aspx. Accessed June 2, 2017.
3. Centers for Disease Control and Prevention. Excessive alcohol use and risks to men’s health.
https://www.cdc.gov/alcohol/fact-sheets/mens-health.htm. Accessed June 2, 2017.
4. Centers for Disease Control and Prevention. Excessive alcohol use and risks to women’s health.
https://www.cdc.gov/alcohol/fact-sheets/womens-health.htm. Accessed June 2, 2017.
5. U.S. Department of Justice. Drinking in America: myths, realities, and prevention policy. Washington, DC: Office of Justice
Programs, Office of Juvenile Justice and Delinquency Prevention; 2005.
http://www.lhc.ca.gov/lhc/drug/DrinkinginAmericaMosherSep26.pdf. Accessed June 2, 2017.
6. Centers for Disease Control and Prevention. Vital signs: binge drinking prevalence, frequency, and intensity among adults —United
States, 2010. MMWR. 2012;61(1):14-19.
7. Tan CH, Denny CH, Cheal NE, Sniezek JE, Kanny D. Alcohol use and binge drinking among women of childbearing age — United
States, 2011–2013. MMWR. 2015;64(37):1042-1046.
8. Willenbring ML, Massey SH, Gardner MB. Helping patients who drink too much: An evidence-based guide for primary care
clinicians. Am Fam Physician. 2009;80(1):44-50.
9. Partnership for Prevention. Preventive care: a national profile on use, disparities, and health benefits. Washington, DC: National
Commission on Prevention Priorities; 2007.
http://www.rwjf.org/content/dam/farm/reports/reports/2007/rwjf13325. Accessed June 2, 2017.
10. McKay JR, Hiller-Sturmhofel S. Treating alcoholism as a chronic disease: approaches to long-term continuing care. Alcohol Res
Health. 2011;33(4):356-370.
11. Prochaska JO, Norcross JC. Stages of change. Psychother. 2001;38(4):443-448.
12. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press; 2013.
13. U.S. Department of Health and Human Services. National action plan to improve health literacy. Washington, DC: Office of Disease
Prevention and Health Promotion; 2010. https://health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf.
Accessed June 2, 2017.
14. Ratzan S, Parker R, Selden CR, Zorn M. National Library of Medicine current bibliographies in medicine: health literacy. Bethesda,
MD: National Institutes of Health, U.S. National Library of Medicine; 2000. https://www.researchgate.net/publication/230877250_
National_Library_of_Medicine_Current_Bibliographies_in_Medicine_Health_Literacy. Accessed June 2, 2017.
15. Petrakis IL, Gonzalez G, Rosenheck R, Krystal JH. Comorbidity of alcoholism and psychiatric disorders. Alcohol Res Health.
2002;26:81–89.
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REFERENCES
Recommended